Postoperative gastric atony after vagotomy for obstructing peptic ulcer

The investigation of diet recovery after distal gastrectomy

This study aims to investigate the adaptation process of the alimentary tract after distal gastrectomy and understand the impact of remnant stomach volume (RSV) on diet recovery.One year after gastrectomy, although patients' oral intake had increased, the RSV was decreased and small bowel motility was enhanced. Patients with a larger RSV showed no additional benefits regarding nutritional outcomes.We prospectively enrolled patients who underwent distal gastrectomy with Billroth II reconstruction to treat gastric cancer at a tertiary hospital cancer center between September 2009 and February 2012. Demographic data, diet questionnaires, computed tomography (CT), and contrast fluoroscopy findings were collected. Patients were divided into 2 groups according to the RSV calculated using CT gastric volume measurements (large vs small). Dietary habits and nutritional status were compared between the groups.Seventy-eight patients were enrolled. Diet volume recovered to 90% of baseline by the 36 postoperative month, and RSV was 70% of baseline at 6 months after surgery and gradually decreased over time. One year after surgery, small bowel transit time was 75% compared to the 1st postoperative month (P < .05); however, transit time in the esophagus and remnant stomach showed no change in any studied interval. Compared to patients with a small RSV, those with a large RSV showed no differences in diet volume, habits, or other nutritional benefits (P > .05).Diet recovery for distal gastrectomy patients was achieved by increased small bowel motility. The size of the remnant stomach showed no positive impact on nutritional outcomes.

Solid Gastric Emptying after Highly Selective Vagotomy and Pyloroplasty in Patients with Obstructing Duodenal Ulcer

Before being superseded by medical management, highly selective vagotomy (HSV) without drainage was the procedure of choice for uncomplicated duodenal ulcer. It is also justified for complications, including perforation and bleeding in selected cases. This prospective study evaluated the effects of HSV plus drainage on solid gastric emptying in 20 patients with chronic duodenal ulcer and pyloric stenosis. Patients were treated with HSV plus pyloroplasty (Heineke-Mikulicz pyloroplasty in five patients, Finney pyloroplasty in six patients and Jaboulay gastroduodenostomy in nine patients) and underwent solid-phase gastric emptying scintigraphic studies pre-operatively and 2 months and 6 months post-operatively. Results were compared with those from 10 controls. No significant differences were observed between the different types of pyloroplasty, although emptying was slightly faster in the gastroduodenostomy group. Gastric emptying returned to normal by 6 months post-operatively. In conclusion, HSV plus pyloroplasty is effective and can be used for the relief of stenosis in selected cases of duodenal ulcer.

Pyloroplasty for Benign Gastric Outlet Obstruction — Indications and Techniques

The understanding of peptic ulcer disease (PUD) etiology, and improvements in treatment during the last two decades, has dramatically decreased the once so frequently performed procedures for PUD and its complications. Benign gastric outlet obstruction may, however, still require operative intervention when non-operative treatment fails. Today, surgeons in training, and even practicing surgeons, may have limited operative experience with procedures required to alleviate an obstructed pylorus. Our aim of this paper is to review the techniques (the Heineke-Mikulicz and Finney pyloroplasties, and modifications) and indications for pyloroplasty in the modern surgical era.

Risk factors associated with delayed gastric emptying after subtotal gastrectomy with Billroth-I anastomosis using circular stapler for early gastric cancer patients

Purpose

Gastric surgery may potentiate delayed gastric emptying. Billroth I gastroduodenostomy using a circular stapler is the most preferable reconstruction method. The purpose of this study is to analyze the risk factors associated with delayed gastric emptying after radical subtotal gastrectomy with Billroth I anastomosis using a stapler for early gastric cancer.

Methods

Three hundred and seventy-eight patients who underwent circular stapled Billroth I gastroduodenostomy after subtotal gastrectomy due to early gastric cancer were analyzed retrospectively. One hundred and eighty-two patients had Billroth I anastomosis using a 25 mm diameter circular stapler, and 196 patients had anastomosis with a 28 or 29 mm diameter circular stapler. Clinicopathological features and postoperative outcomes were evaluated and compared between the two groups. Delayed gastric emptying was diagnosed by symptoms and simple abdomen X-ray with or without upper gastrointestinal series or endoscopy.

Results

Postoperative delayed gastric emptying was found in 12 (3.2%) of the 378 patients. Among all the variables, distal margin and circular stapler diameter were significantly different between the cases with delayed gastric emptying and no delayed gastric emptying. There were statistically significant differences in sex, body mass index, comorbidity, complication, and operation type according to circular stapler diameter. In both univariate and multivariate logistic regression analyses, only the stapler diameter was found to be a significant factor affecting delayed gastric emptying (P = 0.040).

Conclusion

In this study, the circular stapler diameter was one of the most significant predictable factors of delayed gastric emptying for Billroth I gastroduodenostomy. The use of a 28 or 29 mm diameter circular stapler rather than a 25 mm diameter stapler in stapled gastroduodenostomy for early gastric cancer can reduce postoperative delayed gastric emptying associated with anastomosic stenosis or edema with relative safety.

Short-term outcomes of Roux-en-Y stapled anastomosis after distal gastrectomy for gastric adenocarcinoma

BACKGROUND

Since 2003, we have begun to perform gastrojejunostomy by mechanical stapling for Roux-en-Y reconstruction in distal gastrectomy. We performed a retrospective study to compare the short-term outcomes of anastomosis by mechanical stapling and hand suturing.

METHODS

We evaluated the data of 701 consecutive patients of gastric adenocarcinoma who underwent conventional open distal gastrectomy with Roux-en-Y reconstruction. The data collected included details on the method used for the Roux-en-Y reconstruction, the disease stage, extent of lymph node dissection, performance rate of truncal vagotomy, operation time, operative blood loss, length of hospital stay, and postoperative complications.

RESULTS

The operation time was significantly shorter in the group in which mechanical stapling was used for the anastomosis (MS group) than in the group in which anastomosis was performed by hand suturing (HS group; 241.1 +/- 56.8 vs. 166.4 +/- 48.3 min; p < 0.05). Postoperatively, delayed gastric emptying occurred in 14 (1.9%) patients, including seven (4.2%) from the MS group and seven (1.3%) from the HS group (p = 0.038).

CONCLUSION

There were no significant disadvantages of employing mechanical stapling for anastomosis, except for the high rate of delayed gastric emptying. More consideration therefore needs to be given to decreasing the frequency of gastric emptying disturbance post surgery using mechanical staples.

Randomized controlled trial of Roux-en-Y versus rho-shaped-Roux-en-Y reconstruction after distal gastrectomy for gastric cancer

BACKGROUND

The main advantage of the Roux-en-Y (RY) operation is that it prevents bile and pancreatic juice from reaching the gastric mucosa, although the gastrojejunostomy may cause functional delayed gastric emptying (DGE), known as RY stasis syndrome. Rho-shaped Roux-en-Y reconstruction (rRY), an RY reconstruction with a rho-shaped anastomosis, is an established operation that has been found to be effective in preventing DGE.

METHODS

We conducted the randomized trial of RY versus rRY reconstruction after gastric cancer resection. The primary endpoint was the frequency of DGE, and secondary endpoints were the length of postoperative hospital stay, morbidity, and nutritional status. Seventy patients were enrolled, with 35 in each group.

RESULTS

The incidences of postoperative mortality and morbidity did not differ significantly between the two groups. There were no significant differences in nutritional status between the two groups after discharge. Delayed gastric emptying occurred in two patients (6%) in the RY group and four patients (11%) in the rRY group (P = 0.67). Logistic regression analysis revealed that truncal vagotomy was significantly associated with DGE inhibition.

CONCLUSIONS

Our findings showed that RY reconstruction after gastrectomy may be as simple and sufficient as conventional reconstruction.

Vagotomy and Gastrojejunostomy for Benign Gastric Outlet Obstruction

OBJECTIVE

Peptic-ulcer-induced gastric outlet obstruction is an indication for operative intervention. The advent of minimal access surgery allows the conventional open procedure to be performed via laparoscopy.

PATIENTS AND METHODS

From 1996 to 2000, 15 consecutive patients, aged 29 to 75 years, underwent laparoscopic truncal vagotomy and gastrojejunostomy for gastric outlet obstruction. Perioperative data and longterm followup results were analyzed.

RESULTS

There were no conversions or perioperative mortality. The mean operative time was 114 minutes. Patients required on average 1 dose of intramuscular pethidine for analgesia. Eleven patients were discharge by postoperative day 10; the remaining 4 patients had delayed gastric emptying which settled with conservative treatment. With an average followup period of 80 months, patients were classified as Visick I (n = 7), II (n = 5), III (n = 1), and IV (n = 2).

CONCLUSION

Laparoscopic truncal vagotomy and gastrojejunostomy is technically feasible for patients with benign gastric outlet obstruction and is associated with satisfactory perioperative and longterm outcome.

Short air bubble in the gastric fundus during fasting: radiographic sign of gastroparesis after lung transplantation

This study was undertaken to assess whether gastroparesis, as a chronic complication of lung transplantation, correlates with height of the gastric air bubble on chest radiographs of erect fasting subjects. Height of the gastric air bubble and presence or absence of a gastric air-fluid level were assessed on chest radiographic examinations (posteroanterior, lateral, upright position, during fasting, immediately after bronchoscopy, median 148 days after transplantation) obtained on 3 separate days for each of 19 recipients of lung transplantation. Seven of the subjects (five women, two men) had chronic upper gastrointestinal symptoms after transplantation and a confirmed diagnosis of gastroparesis. The gastroparesis was idiopathic in six of the subjects and associated with cytomegalovirus gastritis in one subject. The other 12 subjects, each without upper gastrointestinal symptoms, served as controls. Median height of the gastric air bubble was significantly less in the gastroparetic (2.8 cm; range, 1.0-4.6 cm) than in the control (4.7 cm; range, 1.0-12.4 cm) group (p<0.05). Height of the gastric air bubble was at most 4.6 cm among the seven gastroparetic subjects, whereas it exceeded 5.0 cm on at least one occasion in 8 (67%) of the 12 control subjects (p<0.005). The likelihood of a gastric air-fluid level was 86% for symptomatic subjects and 25% for the control group (p<0.01). When lung transplantation is complicated by chronic gastroparesis, postbronchoscopic chest radiographic examinations of fasting subjects are associated with a gastric air bubble limited to high in the fundus, usually including a fluid level.

Delayed gastric emptying after gastric surgery

BACKGROUND

The reported incidence of delayed gastric emptying (DGE) after gastric surgery is 5% to 25% and usually is based on operations for peptic ulcer disease. Ongoing improvements in perioperative care, nutritional support, and new prokinetic drugs may have had a beneficial effect on the frequency and course of postoperative DGE.

METHODS

We therefore studied our recent experience with DGE in 416 patients who had gastric surgery for ulcer disease (283), cancer (92), or trauma and other indications (41) between January 1985 and December 1993. DGE was defined as inability to eat a regular diet by postoperative day 10.

RESULTS

DGE occurred in 99 of 416 patients (24%). In 75 of these 99 patients, a postoperative contributing factor for DGE was identified. These factors were sepsis (32), anastomotic edema and leaks (23), obstruction (4), pancreatitis (3), multiple system organ failure (5), and miscellaneous conditions (8). In 24 patients there was no obvious cause for DGE; these patients recovered with nutritional support and time. Re-operation specifically for gastric stasis was not performed. Among the 99 patients with DGE, 67% were eating by day 21, 92% by 6 weeks, and 100% by 10 weeks. Significant risk factors for DGE were diabetes (55%), malnutrition (44%), and operations for malignancy (38%). The Whipple procedure had the highest incidence of DGE (70%), highly selective vagotomy the lowest (0%), while truncal vagotomy had no significant effect. The response to metoclopramide was 20% and unpredictable.

CONCLUSION

DGE continues to affect a considerable number of our patients (24%) after gastric surgery and is particularly common in patients with diabetes, malnutrition, and gastric or pancreatic cancer. However, gastric motility does return in 3 to 6 weeks in most patients and the need for re-operation for gastric stasis is rare.

Gastroparesis after lung transplantation. Potential role in postoperative respiratory complications

BACKGROUND

We observed an unexpectedly high incidence of postoperative gastroparesis among lung and heart-lung transplant recipients.

PURPOSE

To identify the incidence of GI complications and to describe the clinical profiles of patients who developed symptomatic gastroparesis after lung transplantation.

PATIENTS AND METHODS

Retrospective study of GI symptoms and complications identified during 3 years of follow-up of 38 adult lung and heart-lung transplant recipients.

RESULTS

Sixteen of 38 patients (42%) reported one or more GI complaint and received a specific GI diagnosis. Nine of 38 patients (24%) complained of early satiety, epigastric fullness, anorexia, nausea, or vomiting. Gastroparesis was suspected when endoscopic evaluation revealed undigested food in the stomach after overnight fast and symptoms could not be attributed to peptide disease or cytomegalovirus gastritis. Delayed gastric emptying was confirmed by gastric scintigraphy. Mean gastric empty (t1/2) was 263 +/- 115 min (normal < 95 min). Gastroparesis occurred in 4 of 13 right lung, 2 of 12 left lung, 1 of 9 bilateral single lung, and 2 of 4 heart-lung recipients (p = NS). Patients responded partially to metoclopramide or cisapride, with the exception of two patients who required placement of jejunal feeding tubes secondary to severe symptoms. In long-term follow-up, symptoms resolved in all patients and treatment with medications or mechanical intervention was successfully discontinued. Four of nine patients (44%) suffering from gastroparesis developed obliterative bronchiolitis (OB). Food particles were discovered in the BAL fluid of two such symptomatic patients. In contrast, only 6 of 29 (21%) nonsymptomatic patients developed OB (p = 0.16).

CONCLUSION

Symptomatic gastroparesis is a frequent complication of lung or heart-lung transplantation that may promote microaspiration into the lung allograft.

Effects of highly selective vagotomy and additional procedures on gastric emptying in patients with obstructing duodenal ulcer

A solid gastric emptying study was conducted on 46 patients more than 1 year after highly selective vagotomy (HSV) and additional procedures for obstructing duodenal ulcer and on 21 patients after HSV alone for uncomplicated duodenal ulcer. The additional procedures included dilatation (n = 14; HSV + D group), Holle pyloroplasty (n = 14; HSV + P group), and Jaboulay gastroduodenostomy (n = 18; HSV + GD group). The test meal consisted of two eggs labeled with 99mTc sulfur colloid, two slices of white bread toast, and 300 ml of orange juice (total 322 kcal). Gastric emptying curves and emptying parameters (t1/2, half emptying time; lag phase, TLAG; emptying rate, k; and beta value) were compared with those of 17 healthy volunteers, the normal control group. The patients after HSV alone had an almost normal gastric emptying. The HSV + D group showed a significant delay from minute 45 to the end of the emptying curve, corresponding to a longer t1/2 (p = 0.02), and a slower emptying rate (p = 0.029). The HSV + P group approached a nearly normal emptying curve, corresponding to an insignificant difference in emptying parameters. The HSV + GD group had significantly faster emptying from minute 15 to the end of the emptying curve, corresponding to a faster t1/2 (p = 0.0005), a shorter lag phase (p = 0.027), and a faster emptying rate (p = 0.021). Recurrent ulcerations were noted in one patient (4.8%) of the HSV alone group, five (35.7%) of the HSV + D group, one (7.1%) of the HSV + P group, and one (5.6%) of the HSV + GD group.(ABSTRACT TRUNCATED AT 250 WORDS)

Gastric motor physiology and pathophysiology

The stomach has two distinct physiologic motor areas: the proximal stomach and the distal stomach. The proximal stomach, with its slow, sustained contractions, has a key role in regulating intragastric pressure and gastric emptying of liquids, while the distal stomach, with its peristaltic contractions, has a major role in mixing, trituration, and emptying of solids. Diseases and operations that disturb the motility of these two areas can result in unique adverse motor sequelae. For example, operations that impair proximal gastric motility, such as proximal gastric resection, may cause rapid gastric emptying of liquids and subsequent dumping and diarrhea. In contrast, operations that impair distal gastric contractions, such as truncal vagotomy, may cause slow gastric emptying of solids and chronic gastric atony. Knowledge of the physiology of the stomach in health and of the pathophysiology with disease and after operation provides a basis for the successful treatment and prevention of these disorders.

Postgastrectomy syndromes

Anatomic and physiological changes introduced by gastric surgery result in postgastrectomy syndromes in approximately 20% of patients. Most of these disorders are caused by operation-induced abnormalities in the motor functions of the stomach, including disturbances in the gastric reservoir function, the mechanical-digestive function, and the transporting function. Division of the vagal innervation to the stomach and ablation or bypass of the pylorus are the most significant factors contributing to postgastrectomy syndromes. Either rapid or slow emptying may result, depending on the relative importance of lack of a compliant gastric reservoir, loss of an effective contractile force, and loss of controlling factors that slow or speed gastric emptying and result in duodenal-gastric reflux. Clearly defining which syndrome is present in a given patient is critical to developing a rational treatment plan. In syndromes with slow gastric emptying, bilious vomiting, or alkaline reflux gastritis, the use of endoscopy is essential to rule out mechanical causes of the syndrome. Contrast radiography and scintigraphic gastric emptying studies are useful to document rapid or delayed gastric emptying. Postgastrectomy syndromes often abate with time. Conservative measures, including medical, dietary, and behavioral therapy, should be given at least a 1-year trial. If these nonoperative measures fail, surgical therapy is recommended. The Roux-en-Y gastrojejunostomy is useful for patients with dumping, because it slows gastric emptying and the transit of chyme through the Roux limb. The same operation helps patients with alkaline reflux gastritis, because it diverts pancreaticobiliary secretions away from the gastric remnant. Near-total gastrectomy, which reduces the size of a flaccid gastric reservoir, can be used to treat delayed gastric emptying. This operation should be combined with the Roux procedure to prevent postoperative reflux gastritis and esophagitis. Newer techniques, such as gastrointestinal pacing and the uncut Roux operation, may improve the treatment of the postgastrectomy syndromes in the future.

Change of gastric liquid emptying after highly selective vagotomy and pyloric dilatation for patients with obstructing duodenal ulcer

Gastric liquid emptying was studied in duodenal ulcer patients with and without stenosis before highly selective vagotomy (HSV) and 1 week, 3 months, and 1 year after. The test meal consisted of 1 mCi of 99m Technetium-diethylene penta-acetic acid (DTPA) in 500 ml of isotonic saline. The patients were divided into 2 groups: group 1 (16 cases) without clinical stenosis, who underwent HSV alone, served as control; group 2 (14 cases) with mild to moderate stenosis, who underwent HSV and transgastric dilatation to 20 mm in diameter. Before HSV, the stenotic group showed a significantly slower liquid emptying than the nonstenotic. Most of the stenotic group could resume a normal diet quickly after operation, but they still had prolonged liquid emptying. At 3 months, the emptying curve of the stenotic patients had approached that of the preoperative controls without a significant difference, while the nonstenotic patients showed an accelerated initial emptying. Although there was a significant improvement with the appearance of accelerated initial emptying at 1 year, the stenotic group still demonstrated slightly slower emptying than the nonstenotic group. A temporary state of preexistent gastric atony due to chronic outlet obstruction may explain the delayed emptying in the early postoperative period; however, minor residual resistance in the fibrotic, scarred tissue was postulated to be persistent despite dilatation, and responsible for the slower emptying of the stenotic than the nonstenotic group at 1 year.

Parietal cell vagotomy and dilatation for peptic duodenal stricture

Gastric outlet obstruction due to peptic duodenal stricture (pyloric stenosis) was treated with parietal cell vagotomy and dilatation of the stricture in 32 patients. Follow-up is in the range of 5 years in 37.4% of the patients, while 6 to 10 years follow-up is available in 62.4% of the patients. At their last follow-up, 74.9% of the patients were in either Visick 1 or 2 clinical status. Recurrence rates have been 3.1% at 1 year, 9.3% at 5 years, and 21.8% after 6 to 10 years follow-up. There has been only one instance (3.1%) of restenosis. Two patients required reoperation because of recurrence and one of them died.